Summary Skyservice Airlines Flight 0045, an AirbusA320-212, registration C-GJUP, serial number 645, was on a regularly scheduled instrument flight rules (IFR) flight. The flight had departed Toronto/LBPIA at 1257 eastern standard time, flew to Windsor where additional passengers were picked up, and then continued to Cancun, Mexico. For the return leg, Flight0045 departed Cancun at 1910 and arrived at Windsor at 2243. At the time of the occurrence, the aircraft was back-taxiing to position on Runway25 in preparation for departure from Windsor. The aircraft radio control of aerodrome lighting (ARCAL) system was in use as the tower had closed during passenger deplaning at the terminal. The airfield lighting extinguished while the aircraft was taxiing to the runway and was not re-activated by the copilot until the aircraft neared the end of the runway. The captain observed the runway end lights after the ARCAL lighting system was activated and applied heavy braking. Because of the aircraft's proximity to the end of the runway and the speed at which it was being taxied, the aircraft did not remain within the confines of the runway. After the aircraft stopped, at approximately 2327 eastern standard time, the flight crew shut down the engines and advised London Flight Information Centre (FIC) of their position. There were no injuries to the passengers or crew. The passengers and flight crew deplaned the aircraft and were bused back to the airport terminal. Ce rapport est galement disponible en franais. Other Factual Information The captain and first officer had not flown together as a crew prior to the day of the occurrence. The captain held a valid airline transport pilot licence (ATPL). He had accumulated over 11000hours total flight time of which over 6600hours were on AirbusA320 aircraft. He was certified and qualified for the flight under existing regulations. He had been awake for 17hours and had been performing duties as a flight crew member for 12hours prior to the occurrence. The captain was seated in the aircraft left seat and was the designated pilot flying (PF). The first officer was an employee of My Travel Airways Ltd., United Kingdom (UK) and was flying for Skyservice Airlines for the winter season as part of a crew sharing arrangement between Skyservice and My Travel. He held a valid UK, Civil Aviation Authority (CAA), ATPL. This licence had been appropriately attached to a Transport Canada, foreign licence validation certificate and was being properly exercised in accordance with the privileges of his UK licence. He had accumulated over 2200hours total flight time of which 450hours were on AirbusA320 aircraft. He was certified and qualified for the flight under existing regulations. He had been awake for 16hours and had been performing duties as a flight crew member for 12hours prior to the occurrence. The first officer was seated in the aircraft right seat and was the designated pilot not flying (PNF). On arrival at Windsor, the air traffic controller advised the flight crew that the control tower would be closed by the time the flight was ready to depart. Five minutes later, the tower closed and the aircraft radio control of aerodrome lighting (ARCAL) system was activated. While the tower is closed, runway and taxiway lighting is controlled by the pilot. The system employed at Windsor airport is defined as a Ktype ARCAL system. This system is activated by pressing the transmit button on the aircraft's very high frequency (VHF) aeronautical radio seven times while tuned to the airport tower frequency of 124.7MHz. Once activated, the airfield lights stay on for fifteen minutes. At any time during the activation time period, the lights may be reset for another 15minutes by pressing the radio transmit button an additional seven times. The current automatic terminal information service (ATIS) stated that the tower was closed and advised vehicles operating on the manoeuvring area to broadcast their intentions on 124.7MHz and to monitor that frequency. En route flight service would be provided by London Flight Service on 126.7MHz. At 2315,1 the aircraft taxied via Golf and Foxtrot taxiways in preparation for departure from Runway25. The crew followed the movement instructions and requested the IFR clearance from London Radio on 126.7MHz. The flight crew did not broadcast their intentions on the aerodrome traffic frequency (ATF) on 124.7MHz. The captain gave a traffic advisory announcing that the aircraft was taxiing on Foxtrot taxiway crossing Runway12; however, this advisory was not communicated on the ATF, 124.7MHz. While the aircraft was taxiing on Foxtrot taxiway, the airfield lighting extinguished and the flight crew continued to taxi the aircraft without activating the ARCAL system. The first officer was unfamiliar with operations at uncontrolled aerodromes, including ARCAL lighting procedures, which resulted in the captain attempting to assist the first officer with his PNF .duties. He directed the first officer to contact London Radio and inform the flight service specialist that they did not observe any snow removal activity and to advise him that nobody was responding to either the tower or ground frequency. The first officer attempted to contact London Radio several times before the flight service specialist asked Flight 0045 to please standby. Shortly after, the flight service specialist contacted the flight crew to relay the IFR departure clearance. It took over three minutes for the first officer to receive the clearance and read it back correctly. The captain then mistakenly broadcast a traffic advisory on 126.7MHz announcing that the aircraft was positioning onto the runway. As the aircraft back-taxied on the runway, the flight crew reviewed the departure clearance, actioned the before take-off checklist, and discussed the lack of runway lighting and the means of activating the ARCAL lighting system. The first officer changed the radio frequency to the ATF 124.7MHz and activated the ARCAL lighting system; the runway edge lights and the threshold end lights illuminated. The captain then saw the end of the runway and applied heavy braking. The aircraft overran the runway, ran over a lighting bar standard damaging a main wheel tire, travelled down a gentle slope, and stopped at a large drainage ditch running perpendicular to the runway. After the aircraft came to a stop, the flight crew communicated with London Radio to apprise the flight service specialist of their situation. The London flight service specialist relayed the flight crew's request for maintenance assistance to the Windsor Airport Security Operations Centre (SOC). SOC requested London FIC to direct the flight crew to communicate on the ATF, 124.7MHz. A digital, ground-speed readout is displayed in front of each pilot in the upper left corner of the navigation display (ND) cathode ray tube (CRT). The flight data recorder (FDR) and cockpit voice recorder (CVR) were secured and forwarded to the TSB Engineering Branch in Ottawa. The FDR revealed that the aircraft ground speed increased to approximately 35knots during the runway back-taxi and remained at that speed for approximately one minute prior to the aircraft exiting the end of the runway. Three seconds after activation of the ARCAL lighting system, the aircraft brake pedals were deflected to a maximum angle of 80degrees. Tire skidmarks were evident at the centre end of the runway. The aircraft heading was relatively constant until the application of brakes. A review of the Windsor ATF recorded transmissions indicated that Staff28, an airport ground vehicle, attempted to contact the flight crew on the ATF as the aircraft was holding short of Runway25. The flight crew did not respond to this communique. After communicating with the firehall and Staff29, Staff28 attempted to contact the flight crew again; however, again there was no response. Moments later, Staff28 observed the aircraft proceed onto the unlit runway and back-taxi. There was no broadcast message for this aircraft movement from the flight crew on the ATF. The aircraft was operating within the manufacturer's specifications for both weight and centre of gravity limitations, and records indicate that the aircraft was properly maintained in accordance with existing regulation. There were no operational or mechanical defects involving either the braking, hydraulic, or nose wheel steering systems. The aircraft's anti-skid system was activated and was functioning properly at the time of the occurrence. The Skyservice A320Flight Crew Operating Manual (FCOM), Standard Operating Procedures (SOPs), includes a directive that ground speed during taxi should be monitored by the flight crew. It further provides guidance to pilots regarding maximum speeds for taxiing and ground manoeuvring. Skyservice FCOM, SOP, Section3.03.10, Page2, states: The normal maximum taxi speed should be 30knots in a straight line, 10knots for a sharp turn. As the ground speed is difficult to assess, monitor ground speed on the ND. Skyservice Airlines company Flight Operations Manual (FOM) enables a document entitled Briefing and Airport Notes. This document is part of the on-board library and contains comprehensive information for flight crews operating into airports that require additional airport specific information. Windsor Airport is not included in this section as an airport requiring extra attention by flight crews. Transport Canada's Aeronautical Information Publication (AIP) includes specific guidance for aircraft operations at uncontrolled aerodromes. AIP, RAC4.5.1, states, in part: An uncontrolled aerodrome is an aerodrome without a control tower, or one where the tower is not in operation. There is no substitute for alertness while in the vicinity of an uncontrolled aerodrome. It is essential that pilots be aware of and look for other traffic, and exchange traffic information when approaching or departing from an uncontrolled aerodrome, particularly since some aircraft may not have communication capability. To achieve the greatest degree of safety, it is essential that all radio-equipped aircraft monitor a common designated frequency, such as the published mandatory frequency (MF) or ATF, and follow the reporting procedures specified for use in an MF area while operating on the manoeuvring area or flying within an MF area surrounding an uncontrolled aerodrome. The AIP provides further specific guidance for pilots operating IFR departures from uncontrolled airports. AIP, RAC7.9, states: Where a pilot-in-command intends to take-off from an uncontrolled aerodrome, the pilot shall: obtain an ATC clearance if in controlled airspace; report on the appropriate frequency his/her departure procedure and intentions before moving on to the runway or before aligning the aircraft on the take-off path; and ascertain by radio on the appropriate frequency and by visual observation that no other aircraft or vehicle is likely to come into conflict with the aircraft during take-off. Skyservice does not include operations at uncontrolled airports in either initial or recurrent ground training for flight crews. The Windsor Airport is a certified controlled airport between the hours of 0630 and 2230 hours local time. Outside of these hours of operation, the airport is uncontrolled, meaning the ATC tower is not staffed. Ground and air movements are facilitated by traffic advisories made over a common radio frequency by the pilots of each aircraft operating on, or in the vicinity of the airport. IFR clearances, en route flight information, and other aviation services are provided by London FIC via remote communication outlet (RCO). Runway edge lighting comprised variable intensity white lights, spaced at 200-foot intervals, at the runway edges along the full length of the runway. There are runway threshold end lights along the width of each runway end. These are variable intensity lights, each of which is coloured red and green. The red is visible while within the confines of the runway and the green is visible while on approach to the runway. The airport has two asphalt-covered runways: runway12/30 is 5150feet long and 150feet wide, and runway07/25 is 9000feet long and 200feet wide. A runway condition report for runway 07/25 taken at 2230 indicated that the runway was 100percent bare and dry. According to the routine aviation weather report (METAR) for 2300, Windsor Airport reported an overcast cloud layer at 2000feet above ground level (agl). Visibility was reported to be 1statute mile (sm) in light snow/ drifting snow. The wind was 240M at 23knots gusting to 31knots. The observation recorded at 2349 reported an overcast cloud layer at 2600feet agl, visibility one and a half sm in light snow/blowing snow and wind 290M at 35knots gusting to 47knots. During taxi and ground manoeuvring operations, blowing and drifting snow can create false impressions of speed and movement. Hawkins, F.H.(1987), Human Factors In Flight, Hants, UK: Ashgate on Illusions In Taxiing writes that in winter, blowing snow may be sweeping across an airfield, giving a false impression of relative movement. Inappropriate control action can be initiated based on this illusion. For instance, an impression can be given that the aircraft is stationary when it is still moving, and a pilot could apply the brakes in a more abrupt manner than he would if he knew the aircraft was moving. Alternatively, the aircraft could slowly creep forward, colliding with an obstruction, when it was thought to be stationary.